On October 3, 2012, an NOV and Proposed Imposition of a Civil Penalty in the amount of $11,200 was issued to Avera McKennan Hospital for a SL II violation involving the failure to maintain written procedures to provide high confidence that each treatment is in accordance with the physician’s written directive as required by 10 CFR 35.41. Specifically, on January 16 and 17, 2012, procedures related to high dose-rate remote afterloader treatments failed to 1) verify a brachytherapy treatment was in accordance with the treatment plan and written directive as required by 10 CFR 35.41(b)(2); 2) check both manual and computer-generated dose calculations as required by 10 CFR 35.41(b)(3); and (3) verify that any computer-generated dose calculations were correctly transferred into the consoles of therapeutic medical units as required by 10 CFR 35.41(b)(4). This violation was repeated, resulting in radiation underexposures to the intended treatment site and exposures to an unintended site on two consecutive days. As a result of the licensee’s performance, the NRC used enforcement discretion in accordance with Section 3.6 of the Enforcement Policy to double the base civil penalty for a SLII violation.